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North Dakota MMIS Companion Guide to the 005010X223A2 Health Care Claim: Institutional (837)
ND Medicaid
May 2017
North Dakota MMIS Companion Guide - Version: 005010X223A2 Health Care Claim: Institutional (837) i
Preface
This Companion Guide to the Accredited Standards Committee (ASC) X12 Technical
Report Type 3 (TR3) and associated errata adopted under HIPAA clarifies and specifies
the data content when exchanging electronically with the North Dakota MMIS.
Transmissions based on this Companion Guide, used in tandem with the v5010 ASC
X12N Technical Report Type 3 (TR3), are compliant with both ASC X12N syntax and
those guides. This Companion Guide is intended to convey information that is within the
framework of the TR3 adopted for use under HIPAA. The Companion Guide is not
intended to convey information that in any way exceeds the requirements or usages of
data expressed in the TR3.
North Dakota MMIS Companion Guide - Version: 005010X223A2 Health Care Claim: Institutional (837) ii
Table of Contents
1 Introduction ............................................................................ 1
Scope ......................................................................................................... 2
Overview ..................................................................................................... 3
References ................................................................................................. 3
Additional Information ................................................................................. 3
2 Getting Started....................................................................... 4
Working with North Dakota Medicaid .......................................................... 4
Scheduled Downtime ......................................................................... 4
Non-Scheduled Downtime .................................................................. 5
Unscheduled/Emergency Downtime ................................................... 7
Trading Partner Registration ....................................................................... 8
Certification and Testing Overview .............................................................. 8
3 Testing with the North Dakota MMIS ..................................... 9
4 Connectivity with the North Dakota MMIS ............................ 10
Process Flows .......................................................................................... 10
Editing and Validation Flow Diagram ................................................ 11
Transmission Administration Procedures .................................................. 12
Re-Transmission Procedures .................................................................... 13
Communication Protocol Specifications .................................................... 13
Web Portal ....................................................................................... 13
ND Enterprise Managed File Transfer .............................................. 17
Passwords ....................................................................................... 17
5 Contact Information ............................................................. 19
EDI Customer Service .............................................................................. 19
EDI Technical Assistance ......................................................................... 19
Provider Services Number ........................................................................ 19
Applicable Web site/E-mail ....................................................................... 20
6 Control Segments/ Envelopes.............................................. 21
ISA-IEA ..................................................................................................... 21
GS-GE ...................................................................................................... 21
ST-SE ....................................................................................................... 21
North Dakota MMIS Companion Guide - Version: 005010X223A2 Health Care Claim: Institutional (837) iii
7 North Dakota Medicaid Specific Business Rules and Limitations .............................................................................. 22
8 Acknowledgements and/or Reports ..................................... 23
Transmission Errors and Reports.............................................................. 23
Transmission Errors .................................................................................. 23
Report Inventory ....................................................................................... 24
TA1 Interchange Acknowledgement Rejection Report ..................... 25
X12C 999 Implementation Acknowledgment .................................... 28
EDIFECS Error Report ..................................................................... 34
9 Trading Partner Agreements ................................................ 38
Trading Partners ....................................................................................... 38
10 Transaction Specific Information ........................................ 39
ASC X12N 837I Health Care Claim: Institutional ....................................... 39
Appendices ............................................................................. 44
Implementation Checklist .......................................................................... 44
Business Scenarios .................................................................................. 45
Transmission Examples ............................................................................ 45
Frequently Asked Questions ..................................................................... 45
Change Summary ..................................................................................... 47
North Dakota MMIS Companion Guide - Version: 005010X223A2 Health Care Claim: Institutional (837) 1
1 Introduction
This 837I Claim Companion Guide is intended for use by Trading Partners in conjunction
with the ASC X12N 837I National Electronic Data Interchange Technical Report Type 3
(TR3). The TR3 can be accessed at http://store.x12.org/store/healthcare-5010-
consolidated-guides.
This Companion Guide outlines the procedures necessary for engaging in Electronic
Data Interchange (EDI) with the North Dakota MMIS and specifies data clarification
where applicable. Section 10 Transaction Specific Information contains provider data
clarifications for fields and values that are specific for the ND MMIS.
Transaction specific data will be detailed using a table. Each row on the table will contain
information on the loop, segment, or data element that is specific to the ND MMIS. The
table format is as described below:
TR3
Page
Loop
ID
Reference Name Codes Length Notes/Comments
84 2010A
A
NM1 Billing
Provider
Name
This type of row
always exists to
indicate that a new
segment has
begun. It is always
shaded at 10%
and notes or
comments about
the segment itself
goes in this cell.
86 2010A
A
NM109 Identificatio
n Code
15 This type of row
exists to limit the
length of the
specified data
element.
109 2000B SBR Subscriber
Information
109 2000B SBR01 Payer
Responsibili
ty
Sequence
Number
Code
A,B,C,D,E,
F,G,H,P,S,
T
These are the only
codes transmitted
by the payer.
North Dakota MMIS Companion Guide - Version: 005010X223A2 Health Care Claim: Institutional (837) 2
TR3
Page
Loop
ID
Reference Name Codes Length Notes/Comments
Payer
Responsibili
ty Eleven
H This type of row
exists when a note
for a particular
code value is
required. For
example, this note
may say that value
H will be used for
all sequences
beyond 10. Not
populating the first
3 columns makes
it clear that the
code value
belongs to the row
immediately above
it.
424 2400 SV2 Institutional
Service Line
425 2400 SV202-1 Product/Ser
vice ID
Qualifier
HC, HP This row illustrates
how to indicate a
component data
element in the
Reference column
and also how to
specify that only
certain values are
applicable.
Scope
This Companion Guide is intended for use by North Dakota Medicaid Trading Partners
for the submission of the X12N 837I transactions to ND Medicaid. This Companion
Document is to be used in conjunction with the 837I TR3.
ND Medicaid provides connectivity for the flow of medical information and data between
medical providers, facilities, vendors, claim payment agencies, clearinghouses and the
North Dakota MMIS Companion Guide - Version: 005010X223A2 Health Care Claim: Institutional (837) 3
Front-end Online Transaction Processor (OLTP). Beyond the receipt and delivery of this
data, ND Medicaid provides translation to and from ASC X12N standard formats.
The 837 Institutional transaction data will be submitted to ND Medicaid for processing
and validation of the X12N format(s). Please refer to Section 4 Connectivity with the
North Dakota MMIS for more information regarding transmission methods.
Overview This Companion Guide is divided into 10 Sections. Each section will describe the process or requirement that each Trading Partner must complete to submit and receive X12N transactions for North Dakota Medicaid. Each section will provide the needed information of how Trading Partners will be required to complete successful transmissions to the North Dakota Medicaid MMIS. This Companion Guide will provide contact information for obtaining assistance from the North Dakota Medicaid MMIS, as well providing data clarifications, including North Dakota Medicaid specific data requirements.
References
This document serves as a companion to the ASC X12N Electronic Data Interchange
Technical Report Type 3 (TR3) as adopted under HIPAA. These can be accessed at:
http://store.x12.org/store/healthcare-5010-consolidated-guides
Additional Information
For more information on North Dakota Medicaid EDI services for providers, including
provider enrollment and claim transaction information, please visit:
https://mmis.nd.gov/portals/wps/portal/EnterpriseHome
North Dakota MMIS Companion Guide - Version: 005010X223A2 Health Care Claim: Institutional (837) 4
2 Getting Started
Working with North Dakota Medicaid
We provide availability for transaction transmission and download retrieval 24 hours a
day, seven days a week. This availability is subject to scheduled and unanticipated non-
scheduled downtime.
Scheduled Downtime
Holiday Schedule
The following days are recognized as official State holidays. Please note that during
these days assistance with system issues will be very limited.
New Year’s Day, January 1
Martin Luther King Day, the 3rd
Monday in January
President’s Day, the 3rd
Monday in February
Memorial Day, the last Monday in May
Independence Day, July 4
Labor Day, the 1st Monday in September
Veteran’s Day, November 11
Thanksgiving Day, the 4th Thursday in November
Christmas Day, December 25
Every day appointed by the President of the United States, or by the Governor
of North Dakota for a public holiday
Routine Maintenance
It is operational policy to schedule preventative maintenance periods on the second
Thursday of the month from 09:00PM to 4:00AM CT. Any alteration from this schedule
will be noted in the notification message as described below.
North Dakota MMIS Companion Guide - Version: 005010X223A2 Health Care Claim: Institutional (837) 5
For Scheduled downtime, a notification message will be published on the Home screen and login screen.
Scheduled downtime – Home Screen
Scheduled downtime – Login Screen
Non-Scheduled Downtime
In the event of a non-scheduled downtime, North Dakota Medicaid will resolve the outage
as quickly as possible. A notification message will be displayed near the Sign In portlet
of the HOME page and near the Login portlet of the Login screen, as noted below. The
anticipated timeframe for resolution will be noted on the message. Also, the message will
state the extent of the disruption, whether it affects the MMIS functionality only, or if it
also affects electronic file transfer processing.
In the event that the file transfer processing is affected, trading partners will receive an
email notification.
North Dakota MMIS Companion Guide - Version: 005010X223A2 Health Care Claim: Institutional (837) 6
Non – Routine Downtime (MMIS and File Transfer affected)– Home Screen
Non – Routine Downtime (MMIS and File Transfer affected)– login Screen
Non – Routine Downtime (File Transfer affected)– Home Screen
North Dakota MMIS Companion Guide - Version: 005010X223A2 Health Care Claim: Institutional (837) 7
Non – Routine Downtime (File Transfer affected)– login Screen
Unscheduled/Emergency Downtime
North Dakota Medicaid will resolve the outage as expeditiously as possible, for Unscheduled/Emergency Downtime. Along with the MMIS notification messages outlined above, the system sends an email notification to the trading partners.
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Trading Partner Registration All entities that send electronic transactions to ND Medicaid for processing and retrieve reports and responses must enroll as EDI Trading Partners. The completed Trading Partner enrollment application provides the ND Customer Service Unit the information necessary to assign a Login Name, Login ID, and Trading Partner ID, which are required to send or retrieve electronic transactions. The Trading Partner enrollment application is available on the North Dakota Medicaid
Web site at https://mmis.nd.gov/portals/wps/portal/ProviderEnrollment
Certification and Testing Overview
X12N transaction files are certified by EDIFECS Transaction Manager software.
Transaction Manager provides accurate trading partner verification and validation of
HIPAA transactions (Type 1 EDI Syntax, Type 2 HIPAA Syntax, and some Type 7 ND
Trading Partner Specific). ND Medicaid requires transaction testing with all enrolling
Trading Partners .
Once a Trading Partner has successfully enrolled with North Dakota Medicaid, they will
be contacted by a ND EDI Specialist. The EDI Specialist will guide the Trading Partner
through the testing process.
.
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3 Testing with the North Dakota MMIS
Before submitting production files to ND Medicaid, the Trading Partner must submit two
valid test files for each transaction type. If the Trading Partner has received a test status
of “Pass”, then ND Medicaid will contact the Trading Partner and update the Trading
Partner status to Production.
These tests verify a Trading Partner’s ability to submit a specific transaction type
containing valid data in the required format. Trading Partners are encouraged to include a
minimum of 10 unique claims per test file to ensure more comprehensive testing.
For each file submission, the Trading Partner will receive an X12C 999 response file and
an Edifecs Error Report in the trading partner’s mailbox. The X12C 999 contains
ACCEPT, REJECT or PARTIAL status. Should Trading Partners receive a test status of
“REJECT” or “PARTIAL”, then the Trading Partner should review the error(s) using the
EDIFECS Error Report. The Trading Partner should correct and resubmit their test file
until it receives a status of “ACCEPT”. If Trading Partners require further assistance with
testing or resolving errors, please contact the ND Customer Service Unit by email at
[email protected], or call 701-328-4043 or 1-800-755-2604 (option 1).
.
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4 Connectivity with the North Dakota MMIS
Process Flows
North Dakota MMIS Companion Guide - Version: 005010X223A2 Health Care Claim: Institutional (837) 11
Editing and Validation Flow Diagram
Legend:
1. Content Identification: Data identification is attempted. If the data can be identified, it is then checked for Trading Partner Relationship Validation.
2. Trading Partner Relationship Validation: The Trading Partner information is validated. If the Trading Partner relationship is valid, the data will be passed for X12N syntax validation.
3. X12N Syntax Validation: A determination will be made as to whether the data is ASC X12N. An X12C 999 (Implementation Acknowledgement) will be sent to the mailbox of the submitter. The X12C 999 contains ACCEPT, REJECT or PARTIAL status. If the file contained syntactical errors, the segment(s) and element(s) where the error(s) occurred will be reported in the X12C 999, and will be further detailed in the EDIFECS Report..
4. Payer Business Edits: If the data passes X12N syntax validation, payer business edits, such as the NPI "check digit" validation" will be performed. Any errors found will be returned in an X12C 999, with
North Dakota MMIS Companion Guide - Version: 005010X223A2 Health Care Claim: Institutional (837) 12
details explaining the segment(s) and element(s) where the error(s) occurred. The X12C 999 will be sent to the Mailbox System for submitter retrieval.
5. Data Transformation: Inbound X12N data is translated to XML format, and passed to the North Dakota MMIS for processing.
Transmission Administration Procedures
Enrolled North Dakota Trading Partners will submit X12N 837 Institutional transaction
data to ND Medicaid for processing. ND Medicaid validates submission of X12N
format(s). The TA1 Interchange Acknowledgement reports the syntactical analysis of the
interchange header and trailer. If the data (Interchange Envelope) is invalid, the file will
be rejected. A TA1 will be delivered to the Trading Partner mailbox and a copy forwarded
to the Trading Partner Support Specialist for review. If the Trading Partner/Transaction
Type relationship does not exist in the Trading Partner Management Database (a missing
or invalid Trading Partner ID), then a TA1 will not be generated because the relationship
does not exist within the ND Medicaid EDIFECS Trading Partner Management
Database.. A report of the TA1 will be generated and delivered to the Trading Partner
Support Specialist for additional review.
An X12C 999 Implementation Acknowledgement is generated when a file has passed the
interchange header and trailer validation. A negative X12C 999 is generated if the file
contains one or more Type 1 or Type 2 EDI or HIPAA Syntax errors or Type 7 ND
Trading Partner Specific errors. The segment(s) and element(s) where the error(s)
occurred will be reported to the submitter in the X12C 999 response.
If you have questions or require assistance with your TA1 or X12C 999 please contact
the Customer Service Unit by email at [email protected], or call 701-328-4043 or
800-755-2604 (option 1)..
North Dakota MMIS Companion Guide - Version: 005010X223A2 Health Care Claim: Institutional (837) 13
Re-Transmission Procedures
Transmission/Production Issues
When file transmission or technical production issues occur, which could require the re-
submission of files, please contact the ND Customer Service Unit by email at
[email protected], or call (701) 328-4043 or (800) 755-2604 (option 1).
Please have the following information available when calling the ND Customer Service Unit regarding transmission and production issues.
Trading Partner ID
Web Portal Login Name (if using the Web Portal)
Enterprise Managed File Transfer (MFT) (if using Secure FTP)
Communication Protocol Specifications North Dakota Trading Partners can submit X12N files and download files such as the X12N 835, X12N 277CA, TA1, and X12C 999 via the ND Health Enterprise MMIS Web Portal and/or Managed File Transfer (MFT).
Web Portal
The Web Portal method allows a Trading Partner to initiate the submission of a batch file
for processing by ND Medicaid. A Trading Partner must be an authenticated portal user
who is either an active North Dakota Provider, or an authorized representative of the
Provider. The Trading Partner accesses the Web Portal via a Web browser and is
prompted for a login and password. Trading Partners may select files for upload from
their PC or work environment using the “Browse” function. All 837 files submitted must
meet the ASC X12N 837 standard.
Note: All files submitted via the Web Portal must be less than 10MB. The File Name can
be a maximum of 80 Characters. A “space” is not allowed in the file name. An
“underscore” may be used in the file name instead of a space.
North Dakota MMIS Companion Guide - Version: 005010X223A2 Health Care Claim: Institutional (837) 14
Web Portal Upload Procedures
1. In your Web browser, log on to the North Dakota MMIS Health Enterprise Portal at https://mmis.nd.gov/portals/wps/portal/EnterpriseHome
2. From the EDI menu, select Upload X12.
3. Navigate to the file you wish to upload using the Browse button, or type the path and filename into the File Information field.
4. Click Submit. Information on the file submitted is displayed in the Upload Completed screen.
5. To retrieve the file confirmation, click on the Message Center button to go to your mailbox.
North Dakota MMIS Companion Guide - Version: 005010X223A2 Health Care Claim: Institutional (837) 15
Web Portal Data Retrieval Procedures
The Web Portal allows a Trading Partner to initiate file retrieval. Once logged into the
Provider Homepage, multiple functions such as File Retrieval are available.
Downloading Files from the Web Portal
1. In your Web browser, log on to the North Dakota MMIS Health Enterprise Portal at https://mmis.nd.gov/portals/wps/portal/EnterpriseHome.
2. From the EDI menu, select File Retrieval Mailbox.
3. Select the X12 radio button; select a file type; and if desired, enter beginning and end dates for the search.
4. Click the Search button. The Results view displays files matching the search criteria. From the Results view, click the Creation Date of the file for downloads.
Note: After the first time selecting the files, the Show All box needs to be checked to retrieve them again
North Dakota MMIS Companion Guide - Version: 005010X223A2 Health Care Claim: Institutional (837) 16
5. Click Save, to save the file to your PC.
6. Specify a path for download, and click Save again.
North Dakota MMIS Companion Guide - Version: 005010X223A2 Health Care Claim: Institutional (837) 17
ND Enterprise Managed File Transfer
ND Enterprise Managed File Transfer (MFT), or commonly referred to as Secure FTP is
an appropriate alternative to the North Dakota Web Portal for large files (i.e. files in
excess of 10MB each). MFT setup is separate from Trading Partner Enrollment, but still
coordinated through the North Dakota Customer Service Unit. Trading partners may use
MFT for submission and retrieval of files. Note that ND Medicaid staff will not provider
technical support for applications other than MFT.
Note: File Name is a maximum of 128 Characters. A “space” is not allowed in the
inbound file name. An “underscore” may be used in the inbound file name instead of a
space.
Managed File Transfer Setup and Support
Upon successful Trading Partner enrollment, a Trading Partner MFT account will be
created. Trading Partners set up for submission and/or retrieval of files via the MFT
mechanism will receive connectivity details from the Customer Service Unit once setup is
complete. This information will include login credentials, policies concerning passwords,
file retention, and basic information on site navigation. The ND Enterprise Managed File
Transfer secured website is https://mft.nd.gov/.
If the Trading Partner requires support (i.e. account becomes locked or experiences
connectivity issues), the Trading Partner should contact the ND Customer Service Unit by
email at [email protected], or call 701-328-4043 or 800-755-2604 (option 1).
Passwords
Log in Credentials: In order to receive your authorized user log in credentials all
Trading Partners, regardless of submission method, must be enrolled with ND Medicaid
and approved as Trading Partners on the ND Health Enterprise MMIS. Log in credentials
include names/ids and passwords, that will be required for the submission of transactions
to ND Medicaid.
Trading Partner ID: The Trading Partner ID links the Trading Partner to their transaction
data and is the ND Health Enterprise MMIS’s internal key to accessing their Trading
Partner information. Please have this number available each time you contact the ND
Customer Service Unit by email at [email protected], or call (701) 328-4043 or (800)
755-2604 (option 1).
The following login credentials are issued depending on the chosen
communication method.
Web Portal User ID/Password: This Web Portal User ID allows Trading Partners
access to the North Dakota MMIS Health Enterprise Portal for functions that include file
submission and file retrieval. The ND Customer Service Unit also uses the logon name
to access Web Portal data submissions.
North Dakota MMIS Companion Guide - Version: 005010X223A2 Health Care Claim: Institutional (837) 18
MFT ID/Password: These are the login credentials for the ND Medicaid Managed File Transfer site. These allow FTP Trading Partners to access assigned folders for file submission or to retrieve responses. The ND Customer Service Unit also uses this secure FTP ID to reference your MFT data submissions.
North Dakota MMIS Companion Guide - Version: 005010X223A2 Health Care Claim: Institutional (837) 19
5 Contact Information
EDI Customer Service
The ND Customer Service Unit is available to all North Dakota Medicaid Trading
Partners, Monday through Friday from 8:00 a.m. to 5:00 p.m., Central Time, at the
following numbers:
Toll Free: (800) 755-2604 (option 1)
Local: (701) 328-4043
EDI Technical Assistance
The ND Customer Service Unit assists users with questions about electronic
submissions. The ND Customer Service Unit is available to all North Dakota Medicaid
Trading Partners, Monday through Friday from 8:00 a.m. to 5:00 p.m., Central Time, at
(800) 755-2604 (option 1) or (701) 328-4043. The Customer Service Unit specializes in
the following:
Provides information on available services
Creates user accounts for file submission for approved Trading Partners
Verifies receipt of electronic transmissions
Provides assistance to Trading Partners experiencing transmission difficulties
Provider Services Number
The ND Customer Service Unit is available to all North Dakota Medicaid Trading
Partners, Monday through Friday from 8:00 a.m. to 5:00 p.m., Central Time, at (800) 755-
2604 (option 1) or (701) 328-4043.
North Dakota MMIS Companion Guide - Version: 005010X223A2 Health Care Claim: Institutional (837) 20
Applicable Web site/E-mail
Please visit https://mmis.nd.gov/portals/wps/portal/EnterpriseHome for ND Medicaid
provider and Trading Partner services information, including Trading Partner enrollment
information, FAQs, manuals and related documentation.
North Dakota MMIS Companion Guide - Version: 005010X223A2 Health Care Claim: Institutional (837) 21
6 Control Segments/ Envelopes
ISA-IEA
ND Medicaid will read the Interchange Control Segments to validate the Interchange
Envelope of each ASC X12 file received for processing. If the Interchange Envelope is
invalid, the Trading Partner will receive a TA1 Interchange Acknowledgement. In the
event a TA1 is generated, the TA1 will be delivered to the Trading Partner Mailbox. The
ISA table provides sender and receiver codes, authorization and delimiter information.
GS-GE
ND Medicaid permits Trading Partners to submit single or multiple functional groups
within an X12 file. If the X12 file contains multiple functional groups, ND Medicaid will
split a file containing multiple functional groups in several files for processing. As a
result, the Trading Partner will receive multiple X12C 999 Implementation
Acknowledgments.
ST-SE
ND Medicaid will require a unique Transaction Set Control Number in the ST02. The
ST02 value should match the SE02 value. Should a file contain multiple ST to SE
Transaction Sets, each transaction set control number may not be duplicated within the
same interchange (ISA to IEA).
North Dakota MMIS Companion Guide - Version: 005010X223A2 Health Care Claim: Institutional (837) 22
7 North Dakota Medicaid Specific Business Rules and Limitations
Many of the data elements detailed in this Companion Guide reflect North Dakota
business requirements, but still meet the standard requirements in the ASC X12N TR3.
Inclusion of a “business-required” data field, as defined by this Companion Guide, will aid
in the delivery of a positive response from the North Dakota Health Enterprise MMIS. For
more information regarding North Dakota specific billing requirements, consult the
applicable ND Medicaid provider billing manual, which can be downloaded from the North
Dakota Medicaid Web site at: https://mmis.nd.gov/portals/wps/portal/EnterpriseHome
Note on decimal/amount fields: Even though the X12N transaction defines Amount
fields as having an 18-byte maximum, there is an additional HIPAA rule that limits all
decimal fields to a maximum of 10 characters, including the two implied or reported
decimal places. Accordingly, for all decimal or amount fields:
“123456789012” is not an acceptable amount, because it is greater than 10 bytes.
“12345678.90” is acceptable because the number of digits is not greater than 10; the decimal point itself is not limited by the rule.
However, “1234567890” is not acceptable because the X12N engine assumes that a decimal point and succeeding zeroes are implied so that the actual number being communicated is “1234567890.00”, which is greater than 10 bytes.
The 10-byte limitation applies to all decimal or amount fields, including AMT segments, but also including any other fields that hold amounts or decimals, such as 837 SV207, CAS03, CAS06, CAS09, CAS12, CAS15, CAS18, HI01-5, HI02-5, HCP02 and HCP03, etc.
For all fields not listed in these bullets, follow the guidelines in the ASC X12N Electronic Data Interchange Technical Report Type 3 (TR3), available at http://store.x12.org/store/healthcare-5010-consolidated-guides.
North Dakota MMIS Companion Guide - Version: 005010X223A2 Health Care Claim: Institutional (837) 23
8 Acknowledgements and/or Reports
Transmission Errors and Reports
Each file submission will create an acceptance or rejection report. The rejection reports
which are generated depend on the severity of the error and the level where the error
occurs. For submissions with errors, the result may be the rejection of an entire file or a
single claim.
Transmission Errors Transmission Errors can occur when there are errors in the ISA segment. The ISA is part of the Interchange Control. A transmission error will occur when the ISA and/or GS Sender and Receiver information is not submitted correctly or does not pass the Edifecs Trading Partner Validation process. When the file is unable to be recognized, an audit report will be generated and posted to the Trading Partner mailbox. If the Trading Partner is unable to be identified in either the ISA or GS, the audit report will still generate and post to a mailbox created for the Trading Partner ID found in the inbound file. The Trading Partner should use the audit report to correct and resubmit their X12 file.
Example: Leading spaces before the start of the data makes the file
unrecognizable. Compliance Check expects “ISA” in the first three spaces.
North Dakota MMIS Companion Guide - Version: 005010X223A2 Health Care Claim: Institutional (837) 24
EDIFECS Audit Report
North Dakota MMIS Companion Guide - Version: 005010X223A2 Health Care Claim: Institutional (837) 25
Report Inventory
The three acceptance/rejection reports are:
TA1 Interchange Acknowledgement
X12C 999 Implementation Acknowledgement
EDIFECS Error Report
TA1 Interchange Acknowledgement Rejection Report
The ISA and GS segments contain the header and trailer information within the
Interchange (ISA-IEA) and Functional Group (GS-GE) envelopes. Some ISA-IEA and
GS-GE problems will result in the entire submission being rejected resulting in the
generation of a TA1 to be delivered to the Trading Partner mailbox. If the Trading
Partner relationship does not exist (a missing or invalid Trading Partner ID), a TA1 will
not be generated because the relationship does not exist within the ND Medicaid Trading
Partner Management Database (TPMS).
A report of the TA1 will be generated daily and delivered to the ND Customer Service
Unit for additional review. For additional information regarding the TA1, please refer to
the ASC X12C 999 (v005010X231A1) Electronic Data Interchange Technical Report
Type 3 (TR3).
The TA1 Interchange Acknowledgement Report may result from various sources:
The submitted file is not recognized as an X12N file due to file corruption or data errors in the ISA-IEA or GS-GE envelopes.
The submitted file has errors that would prevent the translation engine from uniquely identifying the file, transaction type, or submitter.
The ISA01 contains a value other than 00 or 03.
Interchange-Level Errors and the TA1 Rejection Report
Envelope data and/or format issues may make it impossible to identify the ISA-IEA
envelope will result in a TA1 Interchange Acknowledgement rejection of the entire
submission.
An example of an Interchange-Level error that will result in a TA1:
The Header Interchange Control Number in ISA13 (“014640000”) does not match the Trailer Interchange Control Number in IEA02 (“014640001”). The interchange envelope cannot be validated when the ISA13 and IEA02 do not contain the same values.
ISA*00* *00* *ZZ*654321*ZZ*NDDHSMED
*120712*0800*^*00501*014640000*1*T*:~
GS*HC*654321*NDDHSMED*20120712*0800*19990000*X*005010X223A2~
ST*837*1367*005010X223A2~
North Dakota MMIS Companion Guide - Version: 005010X223A2 Health Care Claim: Institutional (837) 26
BHT*0019*00*00020098*20120712*1533*CH~
NM1*41*2*MEMORIAL MEDICAL CENT*****46*103550~
PER*IC*DALE JAMES*TE*9125551212*FX*912551313~
NM1*40*2*ND MEDICAID*****46*NDDHSMED~
HL*1**20*1~
PRV*BI*PXC*193200000X~
NM1*85*2*BILLING PROVIDER*****XX*1104922392~
N3*2010AA ADRESS LINE 1*2010AA ADDRESS LINE 2~
N4*BILLING CITY*ND*033011234~
REF*EI*264646464~
PER*IC*CONTACTNAME*TE*3055551212*EX*2012*FX*3055551313~
HL*2*1*22*0~
SBR*P*18*******MC~
NM1*IL*1*SMITH*JOHN*T***MI*11002225879~
N3*1111 TRAIL PLACE*APT 9S~
N4*SAVANNAH*ND*314011548~
DMG*D8*19530531*M~
NM1*PR*2*ND MEDICAID*****PI*NDDHSMED~
N3*PO BOX 5000~
N4*MCRAE*ND*310555000~
CLM*0630700323*778.18***11:A:1*Y**Y*Y*********Y~
DTP*096*TM*1300~
DTP*434*RD8*20120712-20120712~
DTP*435*DT*201207120000~
CL1*3*1*01~
PWK*05*AA***AC*8265432987654321102012071220120712~
REF*9C*00008033591000001000001~
REF*G1*62362623~
REF*EA*00411733~
NTE*ADD*MEDICAIDGBHC~
HI*BK:7810~
HI*BJ:7810~
HI*BF:3441*BF:4019*BF:07070*BF:0549~
HI*BH:11:D8:20120712*BH:A1:D8:19530531~
NM1*71*1*ATTENDING*PROVIDER*X***XX*1104922392~
PRV*AT*PXC*208600000X~
LX*1~
SV2*0250**547.55*UN*25~
DTP*472*RD8*20120712-20120712~
LX*2~
SV2*0258**100.8*UN*2~
DTP*472*RD8*20120712-20120712~
LX*3~
SV2*0730*HC:93005*129.83*UN*1~
DTP*472*RD8*20120712-20120712~
NM1*72*1*2420BLASTNAME*2420BFIRSTNAME****xx*123456789~
NM1*DN*1*2420CLASTNAME*2420CFIRSTNAME****XX*123456789~
SVD*1234*129.83*HC:00100:22:23*0001*12~
DTP*573*D8*20120712~
SE*51*1367~
GE*1*19990000~
IEA*1*014640001~
North Dakota MMIS Companion Guide - Version: 005010X223A2 Health Care Claim: Institutional (837) 27
Functional Group Level Errors and the TA1 Rejection Report
When the ISA-IEA and GS-GE envelopes are identifiable but the Trading Partner is not
authorized for the transaction, the entire submission is rejected with a TA1.
Example of a Functional-Group-Level error that will result in a TA1 rejection:
If an invalid Receiver ID is transmitted in the GS.
ISA*00* *00* *ZZ*654321 *ZZ*NDDHSMED
*120712*0800*^*00501*014640000*1*P*:~
GS*HC*654321*NDDHSMED*20120712*0800*19990000*X*005010X223A2~
ST*837*1367*005010X223A2~
BHT*0019*00*00020098*20120712*1533*CH~
NM1*41*2*MEMORIAL MEDICAL CENT*****46*103550~
PER*IC*DALE JAMES*TE*91255512124*FX*9125551313~
NM1*40*2*ND MEDICAID*****46*NDDHSMED~
HL*1**20*1~
PRV*BI*PXC*193200000X~
NM1*85*2*BILLING PROVIDER*****XX*1104922392~
N3*2010AA ADRESS LINE 1*2010AA ADDRESS LINE 2~
N4*BILLING CITY*ND*033011234~
REF*EI*264646464~
PER*IC*CONTACTNAME*TE*3055551212*EX*2012*FX*3055551313~
HL*2*1*22*0~
SBR*P*18*******MC~
NM1*IL*1*SMITH*JOHN*T***MI*11002225879~
N3*1111 TRAIL PLACE*APT 9S~
N4*SAVANNAH*ND*314011548~
DMG*D8*19530531*M~
NM1*PR*2*ND MEDICAID*****PI*NDDHSMED~
N3*PO BOX 5000~
N4*MCRAE*ND*310555000~
CLM*0630700323*778.18***11:A:1*Y**Y*Y*********Y~
DTP*096*TM*1300~
DTP*434*RD8*20120712-20120712~
DTP*435*DT*201207120000~
CL1*3*1*01~
PWK*05*AA***AC*8265432987654321102012071220120712~
REF*9C*00008033591000001000001~
REF*G1*62362623~
REF*EA*00411733~
NTE*ADD*MEDICAIDGBHC~
HI*BK:7810~
HI*BJ:7810~
HI*BF:3441*BF:4019*BF:07070*BF:0549~
HI*BH:11:D8:20120712*BH:A1:D8:19530531~
NM1*71*1*ATTENDING*PROVIDER*X***XX*1104922392~
PRV*AT*PXC*208600000X~
LX*1~
SV2*0250**547.55*UN*25~
DTP*472*RD8*20120712-20120712~
LX*2~
SV2*0258**100.8*UN*2~
DTP*472*RD8*20120712-20120712~
LX*3~
SV2*0730*HC:93005*129.83*UN*1~
DTP*472*RD8*20120712-20120712~
North Dakota MMIS Companion Guide - Version: 005010X223A2 Health Care Claim: Institutional (837) 28
NM1*72*1*2420BLASTNAME*2420BFIRSTNAME****XX*1123401478~
NM1*73*1*2420CLASTNAME*2420CFIRSTNAME****XX*1238560147~
SVD*1234*129.83*HC:00100:22:23*0001*12~
DTP*573*D8*20120712~
SE*51*1367~
GE*1*19990000~
IEA*1*014640000~
X12C 999 Implementation Acknowledgment
If the file, envelope, and submitter are recognized, the file is passed through Compliance
Check to determine the syntactical validity of the X12N submission. An X12C 999
Implementation Acknowledgement is generated for all files that receive an accepted TA1.
If errors are found, a rejected or partial X12C 999 will be generated. If the Trading
Partner receives a rejected or partial X12C 999, the Trading Partner will review, correct
and resubmit. For additional information regarding the X12C 999, please refer to the
ASC X12C 999 (v005010X231A1) Electronic Data Interchange Technical Report Type 3
(TR3). If the Trading Partner requires additional assistance with the X12C 999, please
contact the Customer Service Unit.
Interchange Level Errors and the X12C 999 Implementation Acknowledgement
If the Interchange Header is recognizable and all elements are the proper length, but the
header contains syntactically invalid data, such as invalid qualifiers or data relationships,
an X12C 999 will be generated.
Example of an Interchange-Level error that will result in an X12C 999:
“K” is technically a valid repetition separator. An accepted TA1 will be produced. However, if “K” is used anywhere in the file, it will be classified as a repetition separator and it will fail as a syntax error on the X12C 999. ND Medicaid recommends using a caret (^) as the repetition separator.
ISA*00* *00* *XX*654321 *ZZ*NDDHSMED
*120712*0800K*00501*014640000*1*T*:~
GS*HC*654321*NDDHSMED*20120712*0800*19990000*X*005010X223A2~
ST*837*1367*005010X223A2~
BHT*0019*00*00020098*20120712*1533*CH~
NM1*41*2*MEMORIAL MEDICAL CENT*****46*103550~
PER*IC*SKOTT JAMES*TE*9125551212*FX*9125551313~
NM1*40*2*ND MEDICAID*****46*NDDHSMED~
HL*1**20*1~
PRV*BI*PXC*193200000X~
NM1*85*2*BILLING PROVIDER*****ZZ*1104922392~
N3*2010AA ADRESS LINE 1*2010AA ADDRESS LINE 2~
N4*BILLING CITY*ND*033011234~
REF*EI*264646464~
PER*IC*CONTACTNAME*TE*3055551212*EX*2012*FX*3055551313~
HL*2*1*22*0~
SBR*P*18*******MC~
NM1*IL*1*SMITH*JOHN*T***MI*11002225879~
N3*1111 TRAIL PLACE*APT 9S~
N4*SAVANNAH*ND*314011548~
DMG*D8*19530531*M~
NM1*PR*2*ND MEDICAID*****PI*NDDHSMED~
North Dakota MMIS Companion Guide - Version: 005010X223A2 Health Care Claim: Institutional (837) 29
N3*PO BOX 5000~
N4*MCRAE*ND*310555000~
CLM*0630700323*778.18***11:A:1*Y**Y*Y*********Y~
DTP*096*TM*1300~
DTP*434*RD8*20120703-20120708~
DTP*435*DT*201207070000~
CL1*3*1*01~
PWK*05*AA***AC*8265432987654321102012071220120712~
REF*9C*00008033591000001000001~
REF*G1*62362623~
REF*EA*00411733~
NTE*ADD*MEDICAIDGBHC~
HI*BK:7810~
HI*BJ:7810~
HI*BF:3441*BF:4019*BF:07070*BF:0549~
HI*BH:11:D8:20120707*BH:A1:D8:19530531~
NM1*71*1*ATTENDING*PROVIDER*X***XX*1104922392~
PRV*AT*PXC*208600000X~
LX*1~
SV2*0250**547.55*UN*25~
DTP*472*RD8*20120707-20120707~
LX*2~
SV2*0258**100.8*UN*2~
DTP*472*RD8*20120707-20120707~
LX*3~
SV2*0730*HC:93005*129.83*UN*1~
DTP*472*RD8*20120703-20120703~
NM1*72*1*2420BLASTNAME*2420BFIRSTNAME****XX*1123401478~
NM1*73*1*2420CLASTNAME*2420CFIRSTNAME****XX*1238560147~
SVD*1234*129.83*HC:00100:22:23*0001*12~
DTP*573*D8*20120703~
SE*51*1367~
GE*1*19990000~
IEA*1*014640000~
Functional Group Level Errors and the X12C 999 Implementation Acknowledgement
When the GS and GE segments are identifiable and the Trading Partner is authorized for
the transaction, but a syntactical error is identified in the GS or GE segments, the entire
functional group (from GS to GE) is rejected with an X12C 999.
Example of Functional Group Level Error that will result in an X12C 999:
The transaction was built with incorrect Total Number of transaction sets at the Functional Group Trailer. GE01 should be 2 because the Functional Group contains two ST to SE transaction sets.
ISA*00* *00* *ZZ*654321 *ZZ*NDDHSMED
*120712*0800*^*00501*014640000*1*T*:~
GS*HC*654321*NDDHSMED*20120712*0800*19990000*X*005010X223A2~
ST*837*0001*005010X223A2~
BHT*0019*00*00020098*20120712*1533*CH~
NM1*41*2*MEMORIAL MEDICAL CENT*****46*103550~
PER*IC*DALE JAMES*TE*9125551212*FX*9125551313~
NM1*40*2*ND MEDICAID*****46*NDDHSMED~
HL*1**20*1~
PRV*BI*PXC*193200000X~
North Dakota MMIS Companion Guide - Version: 005010X223A2 Health Care Claim: Institutional (837) 30
NM1*85*2*BILLING PROVIDER*****XX*1104922392~
N3*2010AA ADRESS LINE 1*2010AA ADDRESS LINE 2~
N4*BILLING CITY*ND*033011234~
REF*EI*264646464~
PER*IC*CONTACTNAME*TE*3055551212*EX*2012*FX*3055551313~
HL*2*1*22*0~
SBR*P*18*******MC~
NM1*IL*1*SMITH*JOHN*T***MI*11002225879~
N3*1111 TRAIL PLACE*APT 9S~
N4*SAVANNAH*ND*314011548~
DMG*D8*19530531*M~
NM1*PR*2*ND MEDICAID*****PI*NDDHSMED~
N3*PO BOX 5000~
N4*MCRAE*ND*310555000~
CLM*0630700323*778.18***11:A:1*Y**Y*Y*********Y~
DTP*096*TM*1300~
DTP*434*RD8*20120703-20120708~
DTP*435*DT*201207070000~
CL1*3*1*01~
PWK*05*AA***AC*8265432110022258792012071220120712~
REF*9C*00008033591000001000001~
REF*G1*62362623~
REF*EA*00411733~
NTE*ADD*MEDICAIDGBHC~
HI*BK:7810~
HI*BJ:7810~
HI*BF:3441*BF:4019*BF:07070*BF:0549~
HI*BH:11:D8:20120707*BH:A1:D8:19530531~
NM1*71*1*ATTENDING*PROVIDER*X***XX*1104922392~
PRV*AT*PXC*208600000X~
LX*1~
SV2*0250**547.55*UN*25~
DTP*472*RD8*20120707-20120707~
LX*2~
SV2*0258**100.8*UN*2~
DTP*472*RD8*20120707-20120707~
LX*3~
SV2*0730*HC:93005*129.83*UN*1~
DTP*472*RD8*20120703-20120703~
NM1*72*1*2420BLASTNAME*2420BFIRSTNAME****XX*1123401478~
NM1*73*1*2420CLASTNAME*2420CFIRSTNAME****XX*1123856014~
SVD*1234*129.83*HC:00100:22:23*0001*12~
DTP*573*D8*20120703~
SE*51*0001~
ST*837*0002*005010X223A2~
BHT*0019*00*00020098*20120712*1533*CH~
NM1*41*2*MEMORIAL MEDICAL CENT*****46*103550~
PER*IC*DALE JAMES*TE*9125551212*FX*9125551313~
NM1*40*2*ND MEDICAID*****46*NDDHSMED~
HL*1**20*1~
PRV*BI*PXC*193200000X~
NM1*85*2*BILLING PROVIDER*****XX*1104922392~
N3*2010AA ADRESS LINE 1*2010AA ADDRESS LINE 2~
N4*BILLING CITY*ND*033011234~
REF*EI*264646464~
PER*IC*CONTACTNAME*TE*3055551212*EX*2012*FX*3055551212~
HL*2*1*22*0~
SBR*P*18*******MC~
NM1*IL*1*SMITH*JOHN*T***MI*11002225879~
N3*1111 TRAIL PLACE*APT 9S~
N4*SAVANNAH*ND*314011548~
DMG*D8*19530531*M~
NM1*PR*2*ND MEDICAID*****PI*NDDHSMED~
N3*PO BOX 5000~
North Dakota MMIS Companion Guide - Version: 005010X223A2 Health Care Claim: Institutional (837) 31
N4*MCRAE*ND*310555000~
CLM*0630700323*778.18***11:A:1*Y**Y*Y*********Y~
DTP*096*TM*1300~
DTP*434*RD8*20120703-20120708~
DTP*435*DT*201207070000~
CL1*3*1*01~
PWK*05*AA***AC*8265432110022258792012071220120712~
REF*9C*00008033591000001000001~
REF*G1*62362623~
REF*EA*00411733~
NTE*ADD*MEDICAIDGBHC~
HI*BK:7810~
HI*BJ:7810~
HI*BF:3441*BF:4019*BF:07070*BF:0549~
HI*BH:11:D8:20120707*BH:A1:D8:19530531~
NM1*71*1*ATTENDING*PROVIDER*X***XX*1104922392~
PRV*AT*PXC*208600000X~
LX*1~
SV2*0250**547.55*UN*25~
DTP*472*RD8*20120707-20120707~
LX*2~
SV2*0258**100.8*UN*2~
DTP*472*RD8*20120707-20120707~
LX*3~
SV2*0730*HC:93005*129.83*UN*1~
DTP*472*RD8*20120703-20120703~
NM1*72*1*2420BLASTNAME*2420BFIRSTNAME****XX*1123401478~
NM1*73*1*2420CLASTNAME*2420CFIRSTNAME****XX*1123856014~
SVD*1234*129.83*HC:00100:22:23*0001*12~
DTP*573*D8*20120703~
SE*51*0002~
GE*1*19990000~
IEA*1*014640000~
Transaction Set Level Errors and the X12C 999
If an error is identified within the Submitter, Receiver, or Provider loops, the entire
Transaction Set (ST and SE segments and all segments in between) is rejected with an
X12C 999. However, if the functional group consists of additional transactions without
errors, the other transactions will be processed.
Example of a Transaction Set Level Error:
The following example contains an invalid Payer ID of 77101. The Payer ID for ND Medicaid is NDDHSMED.
ISA*00* *00* *ZZ*654321 *ZZ*NDDHSMED
*120712*0800*^*00501*014640000*1*T*:~
GS*HC*654321*NDDHSMED*20120712*0800*19990000*X*005010X223A2~
ST*837*1367*005010X223A2~
BHT*0019*00*00020098*20120712*1533*CH~
NM1*41*2*MEMORIAL MEDICAL CENT*****46*103550~
PER*IC*DALE JAMES*TE*9125551212*FX*9125551313~
NM1*40*2*ND MEDICAID*****46*77101~
HL*1**20*1~
PRV*BI*PXC*193200000X~
NM1*85*2*BILLING PROVIDER*****ZZ*1104922392~
N3*2010AA ADRESS LINE 1*2010AA ADDRESS LINE 2~
N4*BILLING CITY*ND*033011234~
North Dakota MMIS Companion Guide - Version: 005010X223A2 Health Care Claim: Institutional (837) 32
REF*EI*264646464~
PER*IC*CONTACTNAME*TE*3055551212*EX*2012*FX*3055551313~
HL*2*1*22*0~
SBR*P*18*******MC~
NM1*IL*1*SMITH*JOHN*T***MI*11002225879~
N3*1111 TRAIL PLACE*APT 9S~
N4*SAVANNAH*ND*314011548~
DMG*D8*19530531*M~
NM1*PR*2*ND MEDICAID*****PI*NDDHSMED~
N3*PO BOX 5000~
N4*MCRAE*ND*310555000~
CLM*0630700323*778.18***11:A:1*Y**Y*Y*********Y~
DTP*096*TM*1300~
DTP*434*RD8*20120703-20120708~
DTP*435*DT*201207070000~
CL1*3*1*01~
PWK*05*AA***AC*8265432110022258792012071220120712~
REF*9C*00008033591000001000001~
REF*G1*62362623~
REF*EA*00411733~
NTE*ADD*MEDICAIDGBHC~
HI*BK:7810~
HI*BJ:7810~
HI*BF:3441*BF:4019*BF:07070*BF:0549~
HI*BH:11:D8:20120707*BH:A1:D8:19530531~
NM1*71*1*ATTENDING*PROVIDER*X***XX*1104922392~
PRV*AT*PXC*208600000X~
LX*1~
SV2*0250**547.55*UN*25~
DTP*472*RD8*20120707-20120707~
LX*2~
SV2*0258**100.8*UN*2~
DTP*472*RD8*20120707-20120707~
LX*3~
SV2*0730*HC:93005*129.83*UN*1~
DTP*472*RD8*20120703-20120703~
NM1*72*1*2420BLASTNAME*2420BFIRSTNAME****XX*1123401478~
NM1*73*1*2420CLASTNAME*2420CFIRSTNAME****XX*1123856014~
SVD*1234*129.83*HC:00100:22:23*0001*12~
DTP*573*D8*20120703~
SE*51*1367~
GE*1*19990000~
IEA*1*014640000~
Claim-Level Errors and the X12C 999
In a case where header, submitter, receiver, provider, and subscriber loops are all valid,
but an error occurs in a single claim, only the claim containing the error is rejected.
Example of a Claim-Level Error:
In the following example, the Segment ID “REN” is not a valid X12N 837 segment. The highlighted claim (CLM and subsidiary segments) would be rejected with an X12C 999. The claim above it would be passed on for processing.
ISA*00* *00* *ZZ*654321 *ZZ*NDDHSMED
*120712*0800*^*00501*014640000*1*T*:~
GS*HC*654321*NDDHSMED*20120712*0800*19990000*X*005010X223A2~
ST*837*0001*005010X223A2
BHT*0019*00*00020098*20120712*1533*CH~
North Dakota MMIS Companion Guide - Version: 005010X223A2 Health Care Claim: Institutional (837) 33
NM1*41*2*MEMORIAL MEDICAL CENT*****46*103550~
PER*IC*DALE JAMES*TE*9125551212*FX*9125551313~
NM1*40*2*ND MEDICAID*****46*NDDHSMED~
HL*1**20*1~
PRV*BI*PXC*193200000X~
NM1*85*2*BILLING PROVIDER*****XX*1104922392~
N3*2010AA ADRESS LINE 1*2010AA ADDRESS LINE 2~
N4*BILLING CITY*ND*033011234~
REF*EI*264646464~
PER*IC*CONTACTNAME*TE*3055551212*EX*2012*FX*3055551212~
HL*2*1*22*0~
SBR*P*18*******MC~
NM1*IL*1*SMITH*JOHN*T***MI*11002225879~
N3*1111 TRAIL PLACE*APT 9S~
N4*SAVANNAH*ND*314011548~
DMG*D8*19530531*M~
NM1*PR*2*ND MEDICAID*****PI*NDDHSMED~
N3*PO BOX 5000~
N4*MCRAE*ND*310555000~
CLM*0630700323*778.18***11:A:1*Y**Y*Y*********Y~
DTP*096*TM*1300~
DTP*434*RD8*20120703-20120708~
DTP*435*DT*201207070000~
CL1*3*1*01~
PWK*05*AA***AC*8265432110022258792012071220120712~
REF*9C*00008033591000001000001~
REF*G1*62362623~
REF*EA*00411733~
NTE*ADD*MEDICAIDGBHC~
HI*BK:7810~
HI*BJ:7810~
HI*BF:3441*BF:4019*BF:07070*BF:0549~
HI*BH:11:D8:20120707*BH:A1:D8:19530531~
NM1*71*1*ATTENDING*PROVIDER*X***XX*1104922392~
PRV*AT*PXC*208600000X~
LX*1~
SV2*0250**547.55*UN*25~
DTP*472*RD8*20120707-20120707~
LX*2~
SV2*0258**100.8*UN*2~
DTP*472*RD8*20120707-20120707~
LX*3~
SV2*0730*HC:93005*129.83*UN*1~
DTP*472*RD8*20120703-20120703~
NM1*72*1*2420BLASTNAME*2420BFIRSTNAME****XX*1123401478~
NM1*73*1*2420CLASTNAME*2420CFIRSTNAME****XX*1123856014~
SVD*1234*129.83*HC:00100:22:23*0001*12~
DTP*573*D8*20120703~
SE*51*0001
ST*837*0002*005010X223A2~
BHT*0019*00*00020098*20120712*1533*CH~
NM1*41*2*MEMORIAL MEDICAL CENT*****46*103550~
PER*IC*DALE JAMES*TE*9125551212*FX*9125551313~
NM1*40*2*ND MEDICAID*****46*NDDHSMED~
HL*1**20*1~
PRV*BI*PXC*193200000X~
NM1*85*2*BILLING PROVIDER*****ZZ*1104922392~
N3*2010AA ADRESS LINE 1*2010AA ADDRESS LINE 2~
N4*BILLING CITY*ND*033011234~
REF*EI*264646464~
PER*IC*CONTACTNAME*TE*3055551212*EX*2012*FX*3055551313~
HL*2*1*22*0~
SBR*P*18*******MC~
NM1*IL*1*SMITH*JOHN*T***MI*11002225879~
North Dakota MMIS Companion Guide - Version: 005010X223A2 Health Care Claim: Institutional (837) 34
N3*1111 TRAIL PLACE*APT 9S~
N4*SAVANNAH*ND*314011548~
DMG*D8*19530531*M~
NM1*PR*2*ND MEDICAID*****PI*NDDHSMED~
N3*PO BOX 5000~
N4*MCRAE*ND*310555000~
CLM*0630700322*778.18***11:A:1*Y**Y*Y*********Y~
DTP*096*TM*1300~
DTP*434*RD8*20120703-20120708~
DTP*435*DT*201207070000~
CL1*3*1*01~
PWK*05*AA***AC*826543211002225879201207122012071~
REF*9C*00008033591000001000001~
REN*G1*62362623~
REF*EA*00411733~
NTE*ADD*MEDICAIDGBHC~
HI*BK:7810~
HI*BJ:7810~
HI*BF:3441*BF:4019*BF:07070*BF:0549~
HI*BH:11:D8:20120707*BH:A1:D8:19530531~
NM1*71*1*ATTENDING*PROVIDER*X***XX*1104922392~
PRV*AT*PXC*208600000X~
LX*1~
SV2*0250**547.55*UN*25~
DTP*472*RD8*20120704-20120707~
LX*2~
SV2*0258**100.8*UN*2~
DTP*472*RD8*20120704-20120707~
LX*3~
SV2*0730*HC:93005*129.83*UN*1~
DTP*472*RD8*20120701-20120703~
NM1*72*1*2420BLASTNAME*2420BFIRSTNAME****XX*1123401478~
NM1*73*1*2420CLASTNAME*2420CFIRSTNAME****XX*1123856014~
SVD*1234*129.83*HC:00100:22:23*0001*12~
DTP*573*D8*20120703~
SE*51*0002~
GE*2*19990000~
IEA*1*014640000~
EDIFECS Error Report
Every X12N transaction that does not receive a TA1 or X12C 999 transaction rejection
will pass through the EDIFECS Compliance Check engine. EDIFECS generates a full
report of all Loops, Segments, Elements, along with the data contained within them, and
explanations of the errors, if any. This report is especially useful in troubleshooting errors
when it is combined with the X12C 999. The EDIFECS reports will be available to
Trading Partners in their mailbox.
Below is an abbreviated sample Error Report that shows the level of detail contained in
the EDIFECS Error Report. Note that the invalid data is shown in bold type, and the full
explanation of the error is given in the “Error Message” column.
North Dakota MMIS Companion Guide - Version: 005010X223A2 Health Care Claim: Institutional (837) 35
Sample EDIFECS Error Report
Error Report
Submitted: Sunday, August 26, 2012 11:36:50 (Central Time) Guideline: Spec7.ecs Data File: I:\CustomerImplementation\North Dakota\Test Data\837\x12s only\837I – Test
This report shows the results of a submitted data file validated against a guideline. If there are errors, you must fix the application that created the data file and then generate and submit a new data file.
Summary Report Summary
Total Errors: 6 Total Warnings: 0 Total Information: 0
Error Count by WEDI SNIP Type
SNIP Type SNIP Name Counts
0 System 0
1 EDI Syntax 1 Errors 0 Warnings 0 Information
2 HIPAA Syntax 5 Errors 0 Warnings 0 Information
Sample EDIFECS Error Report
# Error
ID
Error Message Error Data SNIP
Type
Severity Guideline Properties
1 0x810024
Element ISA07 (Interchange ID Qualifier) does not contain a valid identification code: ‘PP’ is not allowed. Segment ISA is defined in the guideline at position N/A. This error was detected at: Segment Count: 1 Element Count: 7 Characters: 51 through 53 An invalid code value was encountered.
ISA*00* *00* *ZZ*999 99999 * PP
*NDDHSMED *101201*1107*^*00501*012912196*0*T*
2 – HIPAA Syntax
Normal Element: ISA07
Name: Interchange ID Qualifier
ID: I05
Standard Option:
Mandatory
Type: ID
Min Length: 2
Max Length: 2
User Option: Required
2 0x810024
Element NM108 (Identification Code Qualifier) does not contain a valid identification code: ‘XY’ is not allowed. Segment NM1 is defined in the guideline at position 015.
NM1*85*1*BILLING*PROVIDER*X*** XY
*1104922392
2 – HIPAA Syntax
Normal Element: NM108
Name: Identification Code Qualifier
ID: 66
Standard Option:
Conditional
Type: ID
Min Length: 1
North Dakota MMIS Companion Guide - Version: 005010X223A2 Health Care Claim: Institutional (837) 36
Sample EDIFECS Error Report
# Error
ID
Error Message Error Data SNIP
Type
Severity Guideline Properties
This error was detected at: Segment Count: 11 Element Count: 8 Characters: 443 through 445 An invalid code value was encountered.
Max Length: 2
User Option: Required
3 0x81003C
Element DMG02 (Date Time Period) contains a lexical format rule – the data in this element did not match the rule. The lexical format pattern specified in the guideline is CCYYMMDD. Segment DMG is defined in the guideline at position 032. This error was detected at: Segment Count: 26 Element Count: 2 Characters: 893 through 902 A lexical format mismatch occurred.
DMG*D8* 200601271 *M
2 – HIPAA Syntax
Normal Element: DMG02
Name: Date Time Period
ID: 1251
Standard Option:
Conditional
Type: AN
Min Length: 1
Max Length: 35
User Option: Required
4 0x39393D2
Value of element N403 is incorrect. It should be formatted as 5 or 9 digits for US Zip Code. Segment N4 is defined in the guideline at position 030. This error was detected at: Segment Count: 29 Element Count: 3 Character: 970 through 982 ZIP Code is invalid in Payer City/State/ZIP Code.
N4*MC RAE*ND* 310550000000
2 – HIPAA Syntax
Normal Element: N403
Name: Postal Code
ID: 116
Standard Option:
Optional
Type: ID
Min Length: 3
Max Length: 15
User Option: Required
5 0x810024
Element REF01 (Reference Identification Qualifier) does not contain a valid identification code: ‘XX’ is not allowed. Segment REF is defined in the guideline at position 271. This error was detected
REF* XX
*99999999 2 – HIPAA Syntax
Normal Element: REF01
Name: Reference Identification Qualifier
ID: 128
Standard Option:
Mandatory
Type: ID
Min Length: 2
North Dakota MMIS Companion Guide - Version: 005010X223A2 Health Care Claim: Institutional (837) 37
Sample EDIFECS Error Report
# Error
ID
Error Message Error Data SNIP
Type
Severity Guideline Properties
at: Segment Count: 39 Element Count: 1 Characters: 1256 through 1258 An invalid code value was encountered.
Max Length: 3
User Option: Required
6 0x810005
Element SE02 (Transaction Set Control Number) has a value of ‘1001’. The expected value was ‘10011’. Segment SE is defined in the guideline at position 555. This error was detected at: Segment Count: 87 Element Count: 2 Characters: 2238 through 2242 The values are not equal.
SE*85* 1001 1 – EDI Syntax
Normal Element: SE02
Name: Transaction Set Control Number
ID: 329
Standard Option:
Mandatory
Type: AN
Min Length: 4
Max Length: 9
User Option: Required
North Dakota MMIS Companion Guide - Version: 005010X223A2 Health Care Claim: Institutional (837) 38
9 Trading Partner Agreements
Prior to engaging in EDI with the North Dakota MMIS Enterprise, prospective Trading
Partners must complete a Trading Partner enrollment package, which includes a Trading
Partner Signature Agreement Form that requires an original signature. Please follow all
enrollment instructions and mail the signed Trading Partner Agreement Form to ND
Medicaid, along with any other required documents to complete the enrollment
application process.
Please find all North Dakota Provider/Trading Partner Enrollment information at:
https://mmis.nd.gov/portals/wps/portal/ProviderEnrollment
The mailing address is:
North Dakota Department of Human Services
Attn: Customer Service
600 East Boulevard Avenue, Dept 325
Bismarck, ND 58505-0250
Trading Partners In simple terms, an EDI Trading Partner is defined as any provider or agent acting on behalf of a provider that transmits electronic transaction data to or receives electronic transaction data from a health plan. There are two different types of Trading Partners for the North Dakota Medicaid: First, there are Vendors, Billing Agents, Clearinghouses and Switch Vendors who engage in Electronic Data Interchange (EDI) which may include claims and eligibility inquiries on behalf of enrolled ND Title XIX providers. These Trading Partners are not enrolled providers, their only interaction with the MMIS is to submit and retrieve electronic data files. Second, there are providers re-enrolling under the Title XIX Program who use their own software programs to engage in Electronic Data Interchange (EDI) with the North Dakota Medicaid. Some providers may use the MMIS online file upload and retrieval features via the North Dakota MMIS Health Enterprise Portal.
North Dakota MMIS Companion Guide - Version: 005010X223A2 Health Care Claim: Institutional (837) 39
10 Transaction Specific Information
This section contains data clarifications, including North Dakota-specific data
requirements. For additional guidance on the use of business rules, please see Section
7 North Dakota Medicaid Specific Business Rules and Limitations.
ASC X12N 837I Health Care Claim: Institutional
TR3
Page
Loop
ID
Reference Name Codes Length Notes/Comments
C.3 N/A ISA
Interchange
Control
Header
C.4 N/A ISA05 Interchange
ID Qualifier ZZ
C.4 N/A ISA06 Interchange
Sender ID
Trading Partner ID
assigned by North
Dakota Medicaid
C.5 N/A ISA07 Interchange
ID Qualifier ZZ
C.5 N/A ISA08 Interchange
Receiver ID
NDDHSM
ED
C.7 N/A GS
Functional
Group
Header
C.7 N/A GS02
Application
Sender’s
Code
Trading Partner ID
assigned by North
Dakota Medicaid
North Dakota MMIS Companion Guide - Version: 005010X223A2 Health Care Claim: Institutional (837) 40
TR3
Page
Loop
ID
Reference Name Codes Length Notes/Comments
C.7 N/A GS03
Application
Receiver’s
Code
NDDHSM
ED
68 N/A BHT
Beginning of
Hierarchical
Transaction
69 N/A BHT06 Transaction
Type Code CH
71 1000A NM1 Submitter
Name
72 1000A NM109 Submitter
Identifier
Trading Partner ID
assigned by North
Dakota Medicaid
76 1000B NM1 Receiver
Name
77 1000B NM103 Receiver
Name
ND MEDICAID
77 1000B NM109
Receiver
Primary
Identifier
NDDHSMED
80 2000A PRV
Billing
Provider
Specialty
Information
This segment is required.
80 2000A PRV03 Reference
Identification
Enter the Billing Provider’s Taxonomy Code.
See www.nd.gov/dhs/mmis for appropriate codes.
109 2000B SBR Subscriber
Information
North Dakota MMIS Companion Guide - Version: 005010X223A2 Health Care Claim: Institutional (837) 41
TR3
Page
Loop
ID
Reference Name Codes Length Notes/Comments
109 2000B SBR01
Payer
Responsibilit
y Sequence
Number
Code
A,B,C,D,E,F,G,H,P,S,T
110 2000B SBR09
Claim Filing
Indicator
Code
MC
112 2010BA NM1 Subscriber
Name
114 2010BA NM109
Subscriber
Primary
Identifier
North Dakota Medicaid Subscriber ID. If there are leading zeroes in the suscriber’s ID, include them in this element.
122 2010BB NM1 Payer Name
123 2010BB NM103 Payer Name ND
MEDICAID
123 2010BB NM109 Payer
Identifier
NDDHSMED
166 2300 REF
Payer Claim
Control
Number
166 2300 REF02 Reference
Identification
Required when
CLM05-3 (Claim
Frequency Code)
indicates this claim is
a replacement or
void to a previously
adjudicated claim. If
not required, do not
North Dakota MMIS Companion Guide - Version: 005010X223A2 Health Care Claim: Institutional (837) 42
TR3
Page
Loop
ID
Reference Name Codes Length Notes/Comments
send.
If replacing a claim that was originally processed in the ND Health Enterprise MMIS, Enter the 17-digit TCN for the previously processed claim. If replacing a claim that was originally processed in the ND Legacy MMIS insert the century code in the 3rd and 4th positions of the ICN. Enter the resulting 15-digit ICN for the previously processed claim. Example: Legacy ICN: 1015015320010 Replaced Legacy ICN: 102015015320010
322 2310A PRV
Attending
Provider
Specialty
Information
Situational – this segment required only if the 2310A loop is required.
322 2310A PRV03 Reference
Identification
Enter the Attending Provider’s Taxonomy Code.
See www.nd.gov/dhs/mmis for appropriate codes.
North Dakota MMIS Companion Guide - Version: 005010X223A2 Health Care Claim: Institutional (837) 43
TR3
Page
Loop
ID
Reference Name Codes Length Notes/Comments
354 2320 SBR
Other
Subscriber
Information
355 2320 SBR01
Payer
Responsibilit
y Sequence
Number
Code
A,B,C,D,
E,F,G,H,
P,S,T
North Dakota MMIS Companion Guide - Version: 005010X223A2 Health Care Claim: Institutional (837) 44
Appendices
Implementation Checklist
The North Dakota Customer Service Unit assists new Trading Partners with enrollment
and testing. The following checklist will help trading partners to begin exchanging
information with ND Medicaid.
Trading Partner Checklist
Task Responsibil
ity
Completed
Date
□ Review Trading Partner Enrollment Toolkit at:
http://www.nd.gov/dhs/info/mmis.html
Trading
Partner
□ Enroll in the new MMIS as a Trading Partner at:
https://mmis.nd.gov/portals/wps/portal/ProviderEnroll
ment
Trading
Partner and
ND
Medicaid
□ Exchange Contact information for Business,
Technical and/or Data contacts. (Name, Phone
number, Email address and Mailing Address)
Trading
Partner and
ND
Medicaid
□ Confirm X12 Transaction selections Trading
Partner and
ND
Medicaid
□ Establish Standard ISA and GS information Trading
Partner and
ND
Medicaid
North Dakota MMIS Companion Guide - Version: 005010X223A2 Health Care Claim: Institutional (837) 45
□ Determine communication method Trading
Partner and
ND
Medicaid
□ Establish a schedule for testing Trading
Partner and
ND
Medicaid
□ Complete the testing for all selected X12
Transactions
Trading
Partner and
ND
Medicaid
□ Promote Trading Partner to Production status Trading
Partner and
ND
Medicaid
□ Production cut-over ND
Medicaid
□ Begin sending X12 transactions to new MMIS for
processing
Trading
Partner
Business Scenarios
Please contact the ND Customer Service Unit to discuss your specific EDI related
business needs, should they not be covered in this guide or other available ND Medicaid
X12N transaction companion guides.
Transmission Examples
Please contact the ND Customer Service Unit for transmission examples beyond the
samples already provided in this guide.
Frequently Asked Questions
North Dakota MMIS Companion Guide - Version: 005010X223A2 Health Care Claim: Institutional (837) 46
For current Provider and Trading Partner FAQs, please visit the following page:
https://mmis.nd.gov/portals/wps/portal/ProviderFaq
North Dakota MMIS Companion Guide - Version: 005010X223A2 Health Care Claim: Institutional (837) 47
Change Summary
Version Date Description Description of Changes
1.0 10/10/1012 Initial Document for
Deliverables
Document
reformatted to meet
CAQH CORE
standard companion
guide format (Phase I
CORE Req. 152).
1.1 10/26/2014 Change ND ID Change ND ID from
ND00994 to
NDDHSMED
1.2 05/15/2015 Added requirement for
provider taxonomy codes.
Further defined format of
referenced original ICN/TCN
for replacement/void claims.
Provider Taxonomy
Codes are required
(PRV) when the
provider loop is
required. This
affects 2000A and
2310A.
Loop/segment 2300-
REF02.
If replacing an
original claim
processed in HE
MMIS, then use 17-
digit TCN.
If replacing/voiding
an original claim
processed in legacy
MMIS, insert the
century code in
positions 3 and 4 of
the ICN and enter the
15-digit ICN.
1.3 05/25/2017 Updates related to HIPAA
Operating Rules
requirements
Updated System
Availability section